The ultimate purpose of this project is to inform effective and efficient strategies intended to eliminate both implicit racial bias and the inappropriate effect of patient race on c 4th year medical students' clinical judgments and decisions. There is a huge gap in the needed evidence base. We know very little about the medical school or individual factors that increase or decrease the likelihood of implicit (automatic, unconscious) or explicit bias among graduating medical students. The impact of cultural competence training, informal norms, or school diversity on racial bias is unknown. Furthermore, the determinants of bias may be confounded in ways difficult to disentangle, lowering the utility of studies that only examine a small set of determinants. For example, an observed association between a medical school characteristic and bias may be spurious and due to individual characteristic(s) that predict both medical school choice and likelihood of racial bias. The effect of cultural competence training may be moderated by student characteristics. In response to these considerations, we propose to conduct an innovative multi-measure longitudinal study of a national sample of medical students in order to examine the impact of medical school factors, independent of individual medical student characteristics, on implicit and explicit racial bias in medical students' judgments and decisions. Specifically, we propose to enroll a random sample of 5600 medical students during their 1st year and follow them through the end of their 4th year. We will apply a rigorously developed response rate maximization strategy involving high levels of incentives. Data on individual factors will be collected using web based surveys in students' 1st and 4th year. Since there are no existing valid and comprehensive sources of the medical school factors of interest, we will use survey methodology to obtain such data from a representative sample of students who are completing their medical school education when our cohort is at the end of their second year in medical school. Racial bias will be assessed during the 1st and 4th year of medical school and include: 1) general implicit racial bias and 2) the degree to which patient race influences medical student judgments and decisions in response to written clinical vignettes in which patient race and sex will be randomly assigned and all other patient factors held constant. The impact of medical school factors on implicit racial bias in student's 4th year as well as on the degree to which patient race influences medical students' clinical judgments and decisions will be examined, independent of relevant individual student characteristics. PUBLIC HEALTH RELEVANCE: The ultimate purpose of this project is to inform effective and efficient strategies intended to eliminate both implicit racial bias and bias in clinical judgment and decisions among medical students' judgments and decisions. We propose to conduct an innovative multi-measure longitudinal study of a national sample of medical students in order to examine the impact of individual and medical school factors on implicit and explicit racial bias in medical students' judgments and decisions.